August 13, 2019
According to a study published in JAMA Internal Medicine, out-of-network is occurring more frequently and becoming more costly in both emergency department (ED) and inpatient settings.
Eric C Sun, MD, PhD, Stanford University School of Medicine and colleagues sought to examine the incidence and financial consequences of out-of-network billing, also referred to as surprise billing—which occurs when a patient is treated at in-network facility but seen by an out-of-network clinician and billed accordingly. The surprise comes when the patient is unaware that their treatment is not covered.
The retrospective analysis examined data on health insurance claims for 5,457,981 inpatient admissions and 13,579,006 emergency department admissions between 2010 and 2016 in a large national sample of privately insured patients from all 50 US states. Individuals all had at least 1 bill for 1 out-of-network service or treatment.
From 2010 to 2016, the incident rate of surprise billing increased from 32.3% to 42.8%, with a mean financial responsibility increased from $220 to $628, respectively. Similarly, the study’s results show that the percentage of inpatient admissions with an out-of-network bill increased from 26.3% to 42.0% and the mean potential financial responsibility increased from $804 to $2040.
Costs of increased bills in both categories nearly doubled over the study’s time period, with the top 10% of ED visits resulting in a bill of more than $1,000, and the top 10% of inpatient visits costing more than $3,000.
Dr Sun and colleagues note that out-of-network billing is frequently featured in the media as of late but studies examining its ramifications are lacking.
“Even modest unexpected bills can create financial stress for patients. A recent survey found that 4 in 10 Americans would be unable to pay an unexpected expense of $400 without selling something or borrowing money,” said Dr Sun and colleagues.
The current administration has been proposing legislation to prevent surprise billing. Dr Sun and colleagues note that, “policy solutions centered on disclosure and consent at the point of care may not meaningfully address a large part of the problems patients face,” however, “Policies that limit the ability of physicians and medical transport services to balance bill patients—for example, by shifting some portion of the patient’s responsibility to insurers—offer stronger protection.”
Sun E, Mello M, Moshfegh J, Baker L. Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in In-Network Hospitals [published online August 12, 2019]. JAMA Intern Med. doi10.1001/jamainternmed.2019.345.